Famous bank robber Willie Sutton was reportedly once asked why he robbed banks to which he responded, “because that’s where the money is.” When it comes to income tax identity theft which is still a multi billion problem for the IRS and legitimate taxpayers, the best place to get the most information that can be used for purposes of income tax identity theft is, not surprisingly, the offices of professional tax preparers.

According to the IRS there has been a 60% increase already this year in the number of data breaches at the offices of professional tax preparers. In most instances the data breaches of professional tax preparers begin with a spear phishing email that lures the tax preparer to click on an attachment to the email that downloads malware that enables the cybercriminal to steal all of the information from the tax preparer’s files including clients’ previous tax returns. Identity thieves use that information to file phony income tax returns and claim a fraudulent refund.

Many of these spear phishing emails appear to come from prospective clients looking for a tax preparer. The email purports to have attached W-2s or other documentation that would be needed to file an income tax return. In other instances, the spear phishing email may indicate that the sender is having a problem with the IRS and indicates that attached is a notice from the IRS. In yet other instances, the spear phishing email appears to be an update for tax preparation software used by the tax preparer.

TIPS

Spear phishing is the primary way that malware is sent to not just tax preparers, but also businesses, governmental agencies and all of us as individuals, as well. Never click on links in emails unless you are absolutely sure they are legitimate. If you get such an email from a company, you should always be skeptical and make sure that you call the company or federal agency before considering clicking on the link to confirm whether or not the email is legitimate. Merely because the email uses your name and even your account number does not mean that the email is legitimate. Trust me, you can’t trust anyone. In addition, you should make sure that your computer is protected with security software and install the latest patches and updates as soon as they become available.

If you are not a subscriber to Scamicide.com and would like to receive daily emails with the Scam of the day, all you need to do is to go to the bottom of the initial page of http://www.scamicide.com and click on the tab that states “Sign up for this blog.”

There will be over 90 continuing education seminars and an exhibit floor featuring over 250 innovative companies. Additionally, the Star of the North Meeting provides current clinical and practice management information to the dental community.

In today’s economy, maximizing profitability is not only a desire, but it’s also essential for most practices to stay in business

Now let’s dig in further. If you own a practice, you most likely have an office. That office carries with it many expenses: the most obvious is the monthly rent or mortgage. With an office space also comes staff and payroll as well. These two items are not only needed to have a practice, but are also the two highest expenses for most practices. That being the case, only one of them is really negotiable. You may decide to cut staff, but when it comes to payroll, you either pay people what they are valued at, or they go somewhere that will pay them.

Real estate however, is 100% negotiable. You can decide if you want to be in an office building, retail center or medical office building. You can decide if you lease or own. You can determine the size, location, and amenities your space will offer. You can choose to be in a stand-alone or multi-tenant building. You can determine the length of lease, concessions you ask for, economic terms, business terms, etc.

So if real estate is your second highest expense behind payroll, and if there are so many options and choices to make when it comes to your office space, how can you maximize the opportunity?

To start, you need to understand how the game is played. As a healthcare professional, the playing field is not level. You are a healthcare professional who might engage in 2 to 6 commercial transactions in your career; whereas most landlords and sellers negotiate professionally for a living. You specialize in your field; they specialize in their field. If the outcome was based upon understanding medicine or providing a health related service, you would probably win.

However, the process and outcome are instead based upon comprehensive real estate market knowledge, authoritative posturing, and negotiation expertise. Winning requires having more options, understanding the correct timing, posture and negotiation tactics that landlords use, and in many cases, being able to withstand the stress and conflict that many landlords and sellers use to exploit unsophisticated tenants and buyers.

Let’s focus on a few of these concepts. If you start the transaction at the wrong time, you lose leverage and posture. If you don’t know the market, you are simply begging or bluffing. If you can’t handle conflict, you will most likely receive even more pressure and stress from the landlord or seller to make you uncomfortable and force you into making a decision that you will regret.

And even if you could overcome all of these, without professional representation you are going to be viewed as a novice and are not going to receive the respect that is necessary to achieve the most favorable terms available to you.

Nearly all landlords and sellers hire or consult with professional commercial real estate brokers to give them even more leverage so they can win. Why? Because they understand what is really on the table when it comes to each negotiation. For them, if they give up unnecessary concessions or go lower on rates than they need to, it costs them tens to hundreds of thousands of dollars of profit per lease. The reality is, those are the same items you are trying to maximize and capitalize on.

Large national tenants and buyers understand this concept as well. If you polled fortune 500 companies, you would find they either hire professional representation on every transaction, or they have a team of in-house professionals who are trained and equipped to maximize the opportunity. They understand the potential upside or downside involved in every transaction, and they are committed to getting the best possible terms in every transaction.

Most doctors and administrators don’t understand that commissions in commercial real estate are typically paid the same as they are in residential real estate: by the seller or landlord. This means representation does not cost the practice more money. Fees are set aside in advance and are either used to provide each party with representation, or the landlord or seller keeps that money or gives their broker a double commission.

If you are looking to maximize profitability, start by understanding how much is on the line with your lease or mortgage. Then, make the choice to hire representation that is 100% free to you. Select a commercial real estate broker that understands healthcare, only works for you as the tenant or buyer, can help you find the most options, has the strongest game plan, and who can take and absorb the conflict and confrontation that is inherent in every negotiation that involves a lot of money. In doing so you are positioning yourself to win.

The bottom line is there are tens to hundreds of thousands of dollars available to either be won or lost in every commercial real estate transaction; especially with healthcare real estate. Your profitability affects your patients, your staff, your family, and many others. Maximize every commercial real estate opportunity by taking advantage of the best resources available to you. Winning on your next commercial real estate transaction can transform your practice!

Carr Healthcare Realty is the nation’s leading provider of commercial real estate services for healthcare tenants and buyers. Every year, hundreds of medical, dental, veterinary, and other healthcare practices trust Carr Healthcare Realty to help them achieve the most favorable terms on their lease and purchase negotiations. By not representing landlords or sellers, Carr Healthcare Realty is able to strongly advocate for healthcare providers and avoid conflicts of interest while saving their clients hundreds of thousands of dollars. Carr Healthcare Realty’s team of experts can assist with all types of real estate transactions, including lease renewals, expansions, relocations, startup offices, purchases, and practice transitions.

The CDC Supplement is here. This guide is titled “Summary of Infection Prevention Practices in Dental Settings – Basic Expectations for Safe Care”.

“Transmission of infectious agents among patients and dental healthcare personnel in dental settings is rare. However, from 2003 to 2015, transmission have been documented. . . .The information presented is based primarily upon the recommendations from 2003 guideline and represents infection prevention expectations for safe care in dental settings. . . .Additional topics and information relevant to dental infection prevention and control published by CDC since 2003 in this document can be found.”

This supplement is divided into 5 main sections:

Administrative Measures – Policies and Procedures tailored to dental setting and reassessed annually
Proper supplies and equipment available that are necessary to adhere to standard precautions

Education and training – should be provided during orientation, when new tasks or procedures are introduced and at least annually. Training is to be site specific. Don’t forget about your temporary employees or students. They also need to be trained with the focus on site specific items.

Respiratory Hygiene/Cough Etiquette – measures designed to limit the transmission of respiratory pathogens spread by droplet or airborne routes.

Post signs at entrances with instructions to patients with symptoms of respiratory infections
-cover mouth/nose when sneezing/coughing
-use and dispose of tissues
-preform hand hygiene after hands in contact with respiratory secretions
-provide tissue and no-touch receptacles for disposal of tissue
-provide resources for preforming hand hygiene in or near waiting room
-offer mask to coughing patients

Instrument Reprocessing – Sterilization and disinfection of patient care items and devices:
-manufacturers’ instructions for reprocessing reusable dental instruments and
equipment should be readily available. If there are no reprocessing instructions, it is a
SINGLE use device.
-use single-use devices for one patient only and dispose of appropriately

Dental handpieces and associated attachments including low-speed motors and reusable prophy angles, should always be heat sterilized between patients and NOT high-level or surface disinfected.

–Most everything we use in the dental office has to have FDA clearance as a medical device. The FDA approves label information with part of this being adequate reprocessing instructions to be considered multi-use. They are considering requiring manufacturers to have a 3rd party test their reprocessing before approval would be granted. There are several items they are looking at for example; shade guides, impression guns, composite delivery guns, cerec scanner, multi-use composite & etch syringes, barriers, etc…. and the list goes on.

Burs and Endo file manufacturers also must have adequate reprocessing information and FDA has not seen any so are considered disposable. The instructions need to indicate temperature and type of sterilizer (dynamic air or gravity). Something to look at when purchasing equipment. Would you be able to properly sterilize it?

Back to the slow speed motors. Manufacturers have been instructing us for a long time to sterilize after each use. We have just been ignoring them so the CDC is reinforcing this.

Dental unit water quality – During surgical procedures use only sterile solutions as a coolant/irrigate using an appropriate delivery device, such as a sterile bulb syringe, sterile tubing that bypasses dental unit waterlines, or sterile single-use device.

Remember….Minnesota Rule 3100.6300 REQUIRES all dental health care providers to comply with the CDC guidelines for infection control in a dental setting.

–The new CDC Supplement has a checklist that can be used to access your practice. You can print off the checklist online as a pdf.

Things certainly have changed in the 45 years that I have been a dental technician. I think our industry has never been more exciting than it is right now. Digital laboratory technology is rapidly evolving and this has completely changed the way we design and fabricate dental restorations.

Although most of the impressions we receive are still made with PVS materials and poured up with stone, much of the workflow beyond that point is now digital. The stone model is digitally scanned, the restoration is digitally designed and digitally milled. Milling gives us the ability to adjust the occlusal and proximal contacts to within .01 mm. We have adjustment settings for every client we work with and we fine-tune those settings as we get feedback from you.

To be sure, there is still a lot of human skill involved in finishing, layering, staining and glazing your restorations, but much of the workflow is now digital. With the advent of digital impressioning systems, we will be able to eliminate the inaccuracies inherent in traditional impressioning and poured models. Digital impressioning also makes it easier to create diagnostic wax-ups and allows us to digitally layer the wax-up over the preparation model to duplicate the wax-up in the final restoration design.

Digital technology has also enabled revolutionary changes in dental restorative materials. Ten years ago, dental laboratories were primarily producing porcelain fused to metal and full cast crowns and bridges. Today, we are producing very few of these metal-based restorations…Doctors are instead prescribing highly esthetic lithium disilicate (eMax) and zirconia restorations. These monolithic options are not only better looking, but also stronger than PFMs. For very esthetically demanding situations, our expert technicians can layer porcelain onto these new materials for the ultimate in natural esthetics.

We have been advising you over the last few years to allocate your money where it is needed by primarily prescribing monolithic crowns and prescribing layered anteriors only when needed. A word to the wise about preparation technique for these newer materials: Shoulder preparations are no longer necessary. In fact, they are contraindicated. The new standard is an exaggerated chamfer approximately 1mm wide. This preparation gives the best combination of esthetics and strength and marginal accuracy for these new materials.

You hear a lot about emotional intelligence these days, but what do you know about social intelligence? Social intelligence is the ability to be aware of how others are feeling, in the moment, and manage your behavior in a way that nourishes the relationship. Social intelligence is two-fold: 1-social awareness and 2-relationship management.

Social awareness comes in the form of empathy, situational insight, and having a heart to serve others, all qualities within ourselves we can develop with the help of assessments to establish self-awareness, good coaching, and old fashioned practice-makes-perfect. Learning to put yourself in other’s shoes, picking up on social cues, and doing kind things for others–like buying that box of doughnuts on National Doughnut Day–are skills you can push yourself to embrace and improve upon. Managing relationships can be a little tougher. Whenever people are involved, it’s suddenly no longer just about us (the part we have jurisdiction over).

As much as we’d like to, we just can’t control what others do. But what we can do is focus on our behavior that can help elicit a desirable response from others.

Learning others–who they are, what they are motivated by, where they’ve come from, where they want to go–is a skill that gives us insight into how to manage our relationships toward positive connections. It’s especially important in leadership as we aspire to steer and guide our teams. In order to motivate and inspire employees to reach company objectives and goals, we have to know what makes them ‘tick’. And it’s not a one-size-fits-all formula.

While doughnuts may do the trick for some, others want you to show an interest in their personal life, remembering their birthday and their kids’ names, while others are simply motivated by a raise. Each person comes with their own unique set of history, schema, personality, and skill sets, and discovering what those are with each team member can take a lot of effort — and time.

Are you thinking I have been working as a dentist for a number of years and while I make a good income, I have no idea if I am on track for retirement. How do I take control of my future? The following process can be used to start you on your way.

These documents can be used to look at where you are today and make projections for the future. A Dentist can use one of the following tools to create a financial snapshot: www.mint.com, Quicken Personal Finance or there are a number of apps (https://www.moneyunder30.com/apps-net-worth ).

Step 2: Dentist Financial Goal Setting

The next step for dentists is to determine how much extra savings is needed to achieve your retirement and financial independence goals. There are a number of calculators available on the web that can help identify the target savings number. Just be aware that the assumptions used in the calculators can have a big impact on the results. Another way to look at determining a target number is to use a 4% “safe” withdrawal rate in retirement.

The 4% rule in my opinion is a pretty good indicator of preparedness for financial independence. Example: A dentist’s $3 million dollar investment portfolio can create roughly $120,000 income stream (before taxes). At this rate, a properly diversified portfolio should last 30 years or longer without running out of money. Besides the retirement goal, other goals need to be included and can increase the amount that is required. Examples of other goals include paying for college for children or grand children, extensive traveling, charitable intentions, vacation properties, etc. A good book to read to begin the process of evaluating what retirement might look like is “The New Retirementality” by Mitch Anthony.

Step 3: Dentists, determine what your “gap” is…

After determining the gap between the expected income in retirement and the projected expenses, a plan to fill in the gaps is necessary.

Step 4: Dentists, maximize your savings!

Dentists have a number of vehicles to help build savings!

Maximize contributions to your 401k plan. Up to $54,000 ($60,000 if over age 50) can be contributed for 2017 as an employee and employer.

Explore the possible use of a cash balance pension plan. This type of plan allows for higher contributions to make up ground for retirement savings if needed. The downside is that it can be very complicated to setup and administer.

Contribute to Roth IRA, Back door Roth IRA, Spousal IRA, or Non-Deductible IRAs as allowed depending on income and rules.

Shop around to verify that you are receiving good value for the premium dollars you are spending.

Implement appropriate and recommended coverage.

Step 6: Dentists, do some basic business planning

Run your dental practice like a business. First, develop a business plan and marketing plan.

Determine measures to benchmark the practice and monitor progress to the plans. Measures include profit, patient satisfaction, employee satisfaction, new patients, expenses, etc.

Areas to look at:

Do you want to focus a niche for your practice and then develop it?

Do you need help with Dental Marketing?

Do you have the systems and procedures in place to manage the practice? Think “E-Myth Revisited”by Michael E Gerber.

Does dental patient retention need to be improved?

Review insurance to improve value for the premium dollars spent and to protect the practice.

Most dentists/employers don’t realize the costs of maintaining their retirement plans. Costs can have a significant impact on account growth. If you don’t know the costs, investigate to determine you have a plan with the features you want and are paying a fair fee(s). Also with recent rule changes, business owners have a legal/fiduciary duty that they have a plan that is in the best interests of their employees.

Do you have a place where the people you work with enjoy coming to work? A good working dental team.

Are you utilizing outsourcing as a tool to improve profitability?

Maximize all deductions available to the business.

Consider owning the building your dental practice is in instead of paying rent.

Do you have contingency plans in place should you or a key employee becomes disabled or dies?

Do you have an exit strategy for your business? Buy/sell agreement or plans to bring in a future buyer of your practice?

The bottom line is that you want to maximize the amount you take out of the practice while providing the necessary investment back into the business to achieve your goals.

Step 7: Dentists here are other areas of your plan to consider…

Determine personal cash flow and income needs. Planning cash flow can be very difficult. However, having an accurate picture of expenses now and in retirement can ensure a successful retirement.

Implementing a pay yourself first philosophy can help jump start retirement savings if needed.

Manage debt – Review all personal and business debt. This is often an overlooked aspect for dentists. Appropriate strategies can help increase net worth in the long run. Having consumer debt in retirement can also make it very difficult.

Conduct a tax planning review to verify all available opportunities are being taken advantage of.

Do you have a plan in place to pay for your children’s college education?

Review that appropriate estate planning documents are in place.

There really aren’t any short cuts and you will need to invest time in determining where you are at and then implementing a plan to help achieve your goals in line with your values. If you do so, you can take control.

Proper planning can provide dentists and their families with Peace of Mind. While I work with many types of clients, my dentist clients have found my services especially helpful. Give me a call and I can help make your practice of dentistry a foundation for a great retirement!

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Rick Epple, CFP®, is the founder and president of Aurochs Financial Group (AFG). We at AFG work in our client’s (including dentists) best interest to understand their unique issues and create a flexible but clear and direct road map to achieve your goals. This consists of a comprehensive and integrated wealth management plan and corresponding unbiased custom solution. Our plan will continue to guide and protect our clients in the years ahead, regardless of the changing market and economic condition.

Experience. As a part of your team, Heritage Construction can help guide you through the initial property selection by offering budgetary advice based on countless dental specific projects. This means you can make the most educated property selection for your practice.

Dedication. Heritage Construction knows the value of working within your timeline. We know it is crucial that your practice has minimal downtime. This means less disruption to your clients.

Save you money by doing it right the first time. Heritage Construction takes TEAM seriously. We form alliances with the design team, dental equipment suppliers, and sub-contractors to enhance quality and productivity on your project. This means a more cost effective project to you.

Communication. Heritage Construction maintains a high level of communication to you and the team to include scheduled walk through if desired. Since we value your opinion we listen to your concerns and questions. This means you keep on schedule and as part of your team we help you achieve your desired clinic.

Our mission is to protect and serve our clients with unmatched business professionalism and honesty. We strive to create work environments that are based on respect, and that are rewarding and fun. We will form alliances with our subcontractors and suppliers to enhance job site safety, productivity and cost effectiveness.

Leases and lease renewals are not typically conducted on a level playing field. After all, the landlord is in the real estate business and most doctors are not. By planning ahead and having professional representation, it is possible to negotiate a lower lease rate and receive a substantial tenant improvement allowance and free rent.

How does the lease renewal process work?

An important clause found in a standard lease is the renewal option. This allows you to extend your lease for a predetermined amount of time (often three, five or ten years) by giving your landlord advance written notice. Renewal options include terms for specific lease rates, concessions such as free rent and tenant improvement allowance, and whether a new base year for operating expenses will be granted. Whether or not a renewal clause exists in the original lease, all of these terms are negotiable and play a large role in the financial structure of a lease renewal.
Renewal negotiations are most effective when conducted in the proper timeframe, by having multiple viable relocation options, and creating a strong posture to maintain the upper hand.

When should the process begin?

As a rule of thumb, you should begin to consider the renewal process 12 – 18 months in advance of your lease’s expiration. This is recommended so that you can compare all relocation options in the market before your current lease options expire. Tenants who miss their lease options incur more risk. Landlords view this as an opportunity to push rents higher as the window of opportunity to relocate closes. If tenants holdover (stay in the space after the lease expires), they often see penalties of 150 – 200% of their last month’s rent and can also incur damages if they holdover without permission. The bottom line is that if there is not ample time to relocate if necessary, the landlord has a strong upper hand.

What type of cost savings can be achieved through a successful renewal?

If properly negotiated, you can achieve significant rent savings, a build out allowance, free rent and other concessions. It is very common to start a lease renewal term at a lower lease rate than what you are currently paying. In many markets, landlords are offering aggressive concessions and more attractive lease terms to good tenants to keep their buildings leased and avoid vacancies. The amount of overall savings will depend on the availability of competitive vacancies, the efficiencies of the buildings, and your market knowledge and ability to negotiate business points.

What are some common mistakes practices make during the process?

One of the most common mistakes practices make is negotiating without the help of a commercial real estate professional, specifically one who specializes in representing healthcare providers. Some believe they can save money by not using an agent; but to benefit in real estate, leverage is the key to posture. Landlords are in the real estate business and negotiate with professional guidance. Selecting an expert to represent you provides the leverage needed to receive the best possible lease terms. Further, landlords are typically responsible for paying commissions so professional representation is available to you at no out of pocket cost.

Another mistake practices make when entering into a lease renewal negotiation is not being familiar with their current lease terms and risk exposure. Prior to contacting the landlord about a lease renewal, you should be well aware of your current lease terms including every option and deadline. Most leases contain options that must be exercised within a specific time period, typically six to twelve months prior to the lease’s expiration. If you allow this period to pass, you risk losing all rights outlined in the option, which can cause the negotiations to begin at a disadvantage.

Knowing what you are already paying per square foot is especially important if you are thinking about renewing your lease. What you are paying now versus what buildings are leasing for in your immediate area can be vastly different, especially if your lease has had automatic escalations in the rate over the term of the lease. The way to calculate your price per square foot is to multiply your monthly rent by 12 months and divide it by your square footage. Keep in mind that NNN or CAM charges (operating expenses for the property) are also calculated the same manner.

Summary

Successfully negotiating a lease renewal is more than bartering, bluffing, or asking for a good deal. Landlords and their professional representatives are in the full-time business of maximizing their profits, even if it means taking advantage of uninformed tenants. You can level the playing field by engaging your own professional representation, gaining competitive market knowledge, and by having multiple options for your office space. When done properly, a well-negotiated lease renewal can have a dramatic impact on your practice’s profitability.

Carr Healthcare Realty is the nation’s leading provider of commercial real estate services for healthcare tenants and buyers. Every year, hundreds of medical, dental, veterinary, and other healthcare practices trust Carr Healthcare Realty to help them achieve the most favorable terms on their lease and purchase negotiations. By not representing landlords or sellers, Carr Healthcare Realty is able to strongly advocate for healthcare providers and avoid conflicts of interest while saving their clients hundreds of thousands of dollars. Carr Healthcare Realty’s team of experts can assist with all types of real estate transactions, including lease renewals, expansions, relocations, startup offices, purchases, and practice transitions.

…Horizontally Screw Retained PFM Fixed Partial Denture

By Jeff Benson, DDS

A 65 year old male lost teeth #’s 8 and 9 many years ago and waxed bridge from #6-11 was placed. The #6-11 bridge eventually failed, likely due to a combination of a deep overbite and bruxism. In the pretreatment photo (figure 1), note the gum line fractures of #’s 6, 7, 10 & 11, palatal contact of the lower anterior teeth and loss of bony ridge both vertically and facially. With minimal tooth structure remaining, and with the failure of the previous bridge in mind, it was agreed that an implant supported prosthesis would o er the best outcome for the patient. Implants were placed in #6, 7, 10 and 11 positions.

In order to accommodate both the ridge form and the deep overbite, the lateral implants needed to be angled farther to the facial than ideal, resulting in screw holes which would have exited through the facial surfaces of those restorations. After extensive consultation with the patient and the dental laboratory, an implant supported, CAD/CAM generated, titanium bar mesostructure with a porcelain fused to metal superstructure were chosen to address the overbite, bruxism and screw exit issues. It was anticipated that the parent’s bruxing habit might lead to porcelain damage in the future, so horizontal set screws were employed to make the PFM superstructure easily retrievable for porcelain repairs.

A verification jig (fig 3) was fabricated on the master cast and seated in the mouth (fig 4) to confirm the accuracy of the master cast. A diagnostic mockup (fig 5) was fabricated and tried in the mouth to determine the proper tooth positions for the restoration and to guide the design of the bar. Panthera Dental designed the bar digitally (fig 6) and, once it was milled, the bar was tried in the mouth to verify fit. A new wax mockup which clipped onto the bar was tried into the mouth, and after some minor adjustments, was approved by the patient and the clinician. Once approved, this mockup served as a guide for the fabrication of the overlying PFM framework.

A resin and wax pattern of the PFM superstructure was fabricated directly on the bar (fig 9) and cast with great care to ensure accurate fit around the horizontal set-screws which would secure the superstructure to the bar (fig 10). Once the fit of the superstructure to the bar was conformed, the mockup was used to guide the application of porcelain to create a functional and esthetic simulation of hard and soft tissues with porcelain extending into the ridge defect above #8-9 for esthetics and proper lip support (fig 11 & 12). Particular care was taken to ensure cleanse ability with dental floss and WaterPik. A maxillary night appliance was fabricated to minimize the risk of porcelain fracture due to parafunction.